The nursing home industry remains an important part of the health care continuum, providing housing and health care services to more than 1.5 million older adults in the United States (Centers for Disease Control and Prevention [CDC], 2013). As the population continues to age at an unprecedented rate, the nursing home resident demonstrates higher acuity, more comorbid conditions, and higher care needs than ever before (Mor, Caswell, Littlehale, Niemi, & Fogel, 2009). Nursing homes care for an old, frail population and are devoting more resources to the care and treatment of persons needing short-term rehabilitation, continuous medical monitoring, persons with profound dementia/cognitively impaired and functional disabilities, and the terminally ill. Resident acuity has increased since the 1990s, with many nursing homes providing services and care previously provided only in acute care.
As of 2009, there were approximately 16,000 NHs in the United States with almost 1.6 million Medicare and/or Medicaid certified beds (Centers for Medicare and Medicaid Services [CMS], 2010). Almost 95% of all NHs are dually certified for both Medicare and Medicaid in 2011. NHs average 100 beds; 62% are for-profit, 31%, nonprofit; 7%, government and other. Approximately 54% of for-profit homes are group or chain affiliated, compared to 46% of nonprofit homes.
Despite a reduced bed supply relative to the aging population (e.g., 1999: 141 beds/1,000 75-year-olds; 2004: 117 beds/1,000 75-year-olds), occupancy rates continued to fall from 90% to 98% occupancy in 1999 to 86.3% occupancy in 2009 (CMS, 2010). The decline is attributed to options involving home care options and less restrictive environments such as assisted-living residences as well as reductions in reimbursements (Castle, 2009). Of the 1.5 million nursing home residents, 88% are 65 years and over; 45% represent the 85 and older population. These statistics can be explained by the fact that people are living longer and nursing home care has become more medically sophisticated over the last 15 years.
Approximately 1.5 million people (slightly less than 6% of the elderly cohort) are in a NH on any given day, with 36% admitted from a hospital. Risk factors for admission are advanced age, medical diagnosis, living alone, loss of self-care ability, mental status, race, lack of informal supports, poverty, hospital admission, bed immobility, and female gender. Mentally ill, developmentally disabled, or mentally retarded individuals cannot be admitted to a NH unless the type or intensity of services needed, determined through a formalized screening process, can be provided.
Overall goals of care are to maintain or improve physical and mental function, eliminate or reduce pain and discomfort, offer social involvement and recreational activities in a safe environment, reduce unnecessary hospitalizations and emergency room use, and assure a dignified death. As of 2004, only 1.6% of all nursing home residents received no assistance in activities of daily living (ADL), compared to 51% receiving assistance in five ADL domains (CMS, 2010). NHs must provide dental, podiatric, and medical-specialty consultation services; social services; and mental health and nutrition services. Some homes have fully equipped dental, podiatric, and X-ray suites, laboratory facilities, and pharmacies.
All NHs provide care at the end of life. Approximately 78% of NHs provide hospice care although this can vary from a consultative relationship with a certified hospice agency to one in which the resident's care is planned, managed, and monitored by the hospice agency in the NH. Residents receiving hospice services have better pain management, fewer hospitalizations, and less use of feeding tubes than residents receiving standard end-of-life care.
Virtually all homes provide rehabilitative services (i.e., physical therapy, occupational therapy, speech, and hearing), but the intensity of the service varies with the home's program operation and Medicare participation.
Slightly more than 15% of NHs have formally designated Special Care Units (SCUs), constituting approximately 7% of all NH beds. These units care for residents with dementias, hospice, rehabilitation, and ventilator-dependent residents.
Most NH residents are White (86%) and female (71%); 12% are under 65 years of age. Black residents were twice as likely as White residents to be under the age of 65. The most frequent admission diagnoses were related to diseases of the circulatory system, mental disorders, ad diseases of the nervous system (CMS, 2010). As of 2009, nearly 50% of residents were either totally dependent or required extensive assistance with bathing, dressing, toileting, and transferring; 32% were bowel incontinent, while 34% were bladder incontinent.
Approximately 65% of NH residents have some degree of dementia; 20% of all residents have at least one symptom of clinical depression, particularly those age 65 to 84 years. The percentage of residents receiving psychoactive medication increased from 48% in 1998 to 63% in 2004 (Harrington, Carrillo, & Mercado-Scott, 2010). One third of residents have inappropriate or dangerous behavior. The use of physical restraints decreased from 12.5% of residents in 1998 to 7.5% in 2004 and is attributed to increased regulatory oversight and staff education (Harrington et al., 2010).
According to Wang, Shah, Allman, and Kilgore (2011), nursing home residents are prominent users of the emergency department, accounting for more than 2.2 million visits annually. Additional findings included that nursing home residents had higher acuity than nonnursing home residents, were more likely to be admitted to the hospital, exhibited higher mortality, and were more likely to have been discharged from the hospital within the prior 7 days. Influences on hospitalization decisions include physician practice pattern in the NH and local area, hospital vacancy rate, Medicare eligibility, staff and family pressure, NH resources (e.g., diagnostic services, IV therapy, insufficient RNs, systemic infectious processes, cost of antibiotic therapy, pulmonary disease, payment source, and advanced age).
Of all NH residents, 65% have some form of advance directive (including Do Not Resuscitate [DNR]); 66% of all residents die in the NH. An anticipated increase in Do-Not-Hospitalize (DNH) requests (currently, 4% to 6% of NH residents) and refusal of life-sustaining interventions will likely result in fewer hospitalizations and more “planned deaths” in nursing homes.
The average length of stay (LOS) for long-term residents is 835 days. Justification of continued-stay review, intensive rehabilitation, and aggressive outplacement to cheaper, lesser levels of care, such as assisted-living or home care, are resulting in shorter nursing home length of stay. Increasingly, more residents are being discharged back to the community, “recovered or stabilized.”
Of the 1.5 million full-time equivalent (FTE) employees in NHs in 2004, almost two thirds were nursing staff (i.e., RN, LPN, Certified Nurse Assistant [CNA]). Nursing staff turnover is pervasive, costly, and impacts negatively on quality of care. In some states, CNA turnover exceeds 100% annually. Turnover is associated with staffing levels lower than in comparable NHs, poor quality of care, larger facilities, and for-profit ownership (Castle & Engberg, 2009). The “interdisciplinary team” consisting of nursing and social services, activities, a dietitian, rehabilitation therapist, and physician, are accountable for resident care and outcomes.
Nursing homes with 60 or more residents require an RN must be on duty 8 consecutive hours per day, 7 days per week. An RN or LPN must be used for the remaining 16 hours. Total nursing care hours per resident day increased from 3.1 hours in 1991 to 3.7 hours in 2004 (Harrington, Carrillo, & Mercado-Scott, 2010). On average, current staffing per resident day is RNs, 0.6 hour; LPNs, 0.7 hour; CNAs, 2.3 hours. Several studies found a positive relationship between RN staffing and quality outcomes.
Every resident must have a physician who is legally responsible for the plan of care. Few NH physicians are certified geriatricians. A full-time NH physician can have 60 to 80 residents and also serve as the medical director. Every NH is required to have a medical director, on-site a minimum of 20 hours per week, with responsibilities that include quality improvement, patient services, resident rights, and administration (Office of Inspector General, 2012).
Twelve percent of NHs have no physical therapists; 20% have no occupational therapist; 26% have no speech/language therapist. The number of social workers, activity therapists, and nutritionists varies with facility size. Nursing home administrators must be licensed and, in most states, have a bachelor's degree in long-term-care administration or a related (health) field.
Approximately 65% of NH residents are dually eligible (Medicare/Medicaid) beneficiaries; 29.7% have Medicare only, and less than 5% have Medicaid only. Medicaid is the primary payer for approximately 63% of NH residents. Private pay accounted for 44% of NH revenue in 1985, 28% in 1996, and 22% in 2011; private insurance, 3% to 4%; public/charity, 3%. Whereas at time of admission a dual-beneficiary resident is likely to be Medicare-covered, Medicaid is likely to cover the extended-stay non-Medicare portion of NH residence. The Medicare component of the NH program remains essentially restricted to 100 days of only posthospital skilled nursing and/or skilled rehabilitation. The average national daily cost of a semiprivate nursing home bed is $222. In 2011, Medicare spent almost $32 billion on skilled nursing facility care.
Implementation of a prospective payment system (PPS) for Medicare reimbursement in 1998 (Balanced Budget Act [BBA] P.L.105–33) placed NHs under increasing pressure to maximize revenue and reduce costs. This system shifted payment from a cost-based system with limits for routine operating costs, to a per-diem payment system based on a resident's “resource use group” (RUG) defined by the types of services required and other resident characteristics (Huckfeldt, Sood, Romley, Malchiodi, & Escarce, 2013). At least 17 states are using some kind of case-mix reimbursement system that classifies residents into homogeneous resource utilization groups (RUGs) and links reimbursement to residents’ characteristics and resource use. Almost two thirds of Medicare-covered NH stays in 1999 were provided to residents in three of the five Rehab RUG-III groups and in the Extensive Care RUG-III Group (HCFR, 2011).
In 1987, nursing homes were subject to sweeping reforms contained in the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) or Nursing Home Reform Law. Nursing homes have an unannounced survey every 9 to 15 months by a state's health department acting as agents for the CMS. There can be a “look-behind” survey by federal Medicare surveyors. The CMS Web site, NH Compare, provides NH-specific data that include 12 long-term and 3 short-stay quality measures and compare NHs within states and with national benchmarks. Review and accreditation by The Joint Commission on Accreditation of Healthcare Organizations is optional for all NHs but mandatory for hospital-based NHs and those seeking managed-care contracts or affiliations.
Quality-of-care and quality-of-life deficiencies are characterized by their scope (i.e., number of residents potentially or actually affected) and severity. The two most frequently cited deficiencies in 2011 were related to infection control (35% of all NHs) and failure to prevent accidents and injuries (28%). The top 10 deficiencies concerned accidents, resident dignity, pressure sores, and comprehensive care planning (CMS, 2010). Pain management has improved significantly. Reduction in problems with quality, since 1999, might be attributable to inconsistencies in how states conduct surveys and understatement of serious deficiencies (Government Accountability Office, 2010).
At least 46% of the elderly population of the United States will spend some time in a NH. The potential for technology to improve quality of care and quality of life in NHs includes falls prevention (e.g., chair alarms, rehab equipment to improve strength), wandering management (i.e., low- or high-tech), incontinence care (e.g., voiding reminders), and passive call systems. Barriers to implementation include NHs’ lack of experience and skill in application of advanced technologies; absence of industry standards and applicable regulations regarding use of the technologies; and insufficient financing.
The notion of culture change, articulated by the Pioneer Movement in the late 1990s, has captured the attention of the NH industry as well as those who regulate it, set policy, and seek to improve quality of care and quality of life. Nursing homes are reinventing themselves so that resident dependency, in part a product of the institutional model, is less likely to occur and a model that supports resident growth and creativity—through person-centered care and staff empowerment—is created. Emerging best practices in nursing homes include mentoring programs, staff involvement (i.e., empowerment) in decision making, flexible work schedules, data-driven plan of care, family involvement, and a home-like environment that includes resident choices and input into facility operations (OIG, 2009).
See also Advance Directives; Assisted Living; Dementia: Special Care Units; Nursing Home Managed Care; Nursing Home Reform Act.
- Factors associated with increasing nursing home closures. Health Services Research, 44, 1088-1109. ; (2009).
- Center for Disease Control and Prevention. (2013). Nursing home care. Retrieved from http://www.cdc.gov/nchs/fastats/nursingh.htm.
- Center for Medicare and Medicaid Services. (2010). Nursing home data compendium. Retrieved from http://www.cms.gov/Medicare/nursinghomecompendium_508.pdf.
- Government Accountability Office. (2010). Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are UnclearGAO-10-434R, Apr 28, 2010. Retrieved from http://www.gao.gov/products/GAO-10-434R Available at http://www.gao.gov/new.items/d07794t.pdf.
- Nursing facilities, staffing, residents, and facility deficiencies, 2005-2010. Department of Social and Behavioral Sciences. University of California San Francisco, CA. ; ; (2010).
- Health Care Financing Review. (HCFR; 2011). Medicare and medicaid statistical supplement. U.S. Department of Health and Human Services, Health Care Financing Administration Baltimore, MD.
- Medicare payment reform and provider entry and exit in the post-acute care market. Health Services Research. ; ; ; ; (2013).
- Changes in the quality of nursing homes in the U.S.: A review and data update. Retrieved from http://www.ahcancal.org/research_data/quality/Documents/ChangesinNursingHomeQuality.pdf. ; ; ; ; (2009).
- Office of the Inspector General. (OIG; 2012). National medical director survey. United States Department of health and Human Services Washington, DC. OEI-06-99-00300.
- Office of the Inspector General (OIG; 2009). Emerging practices in nursing homes. United States Department of health and Human Services Washington, DC. OEI-01-04-00070.
- Emergency department visits by nursing home residents in the United States. Journal of the American Geriatrics Society, 59, 1864-1872. ; ; ; (2011).
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